A Medical-Surgical nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?
"Do not adjust the oxygen flow rate.”
"Check your oxygen equipment once each week.”
"Store unused oxygen tanks horizontally.”
"Use wool blankets on your bed.”
The Correct Answer is A
Choice A rationale:
Instructing the client not to adjust the oxygen flow rate is crucial to ensure the appropriate amount of oxygen is delivered. Oxygen flow rates are prescribed by a healthcare provider based on the client's needs, and altering the flow rate without medical guidance can lead to inadequate oxygen delivery or oxygen toxicity.
Choice B rationale:
Weekly equipment checks are important, but this choice is not the most critical instruction. Clients should be instructed to check their oxygen equipment daily for proper functioning and to address any issues promptly. Waiting a whole week could lead to potential problems going unnoticed.
Choice C rationale:
Storing unused oxygen tanks horizontally is incorrect. Oxygen tanks should be stored upright to prevent leaks and ensure proper functioning. Storing them horizontally can cause valve damage and leakage, which could lead to hazards.
Choice D rationale:
Using wool blankets on the bed is not a suitable instruction for a client using oxygen therapy. Wool blankets can generate static electricity, which might pose a fire hazard in the presence of oxygen-enriched environments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale:
Drowsiness alone may not be a reliable indicator of pain, as it can result from various factors such as medications or the postoperative recovery process. While pain might cause drowsiness in some cases, it is not a definitive nonverbal sign of pain.
Choice B rationale:
Grimacing is a nonverbal behavior that often indicates pain or discomfort. It involves facial expressions of pain, such as frowning or wincing. Grimacing is a significant indicator that the nurse should consider in assessing the client's pain level.
Choice C rationale:
Screaming is a more overt expression of pain and discomfort. However, it is less common in a postoperative setting and might also be associated with anxiety or other emotional states. While it can indicate pain, it's not as reliable a marker as grimacing, moaning, or restlessness.
Choice D rationale:
Moaning is a nonverbal behavior that can signal pain in a postoperative client. It's an audible expression of discomfort and should be considered as a potential indication of pain.
Choice E rationale:
Restlessness can be an indication of pain as well. The client may shift positions frequently or exhibit signs of agitation in response to pain. However, restlessness can also have other causes, such as anxiety or medication effects.
Correct Answer is D
Explanation
Choice A rationale:
Helping the client select a low-salt diet is not directly related to addressing tenacious bronchial secretions. While a low-salt diet might have some implications for overall cardiovascular health, it doesn't specifically address the issue of secretions in the lungs.
Choice B rationale:
Encouraging the client to drink 2 to 3 L of water daily is generally beneficial for maintaining hydration and thinning mucus secretions. However, it doesn't directly address the problem of not being able to bring up secretions. Other interventions are more suitable for that issue.
Choice C rationale:
Administering oxygen via nasal cannula at 2 L/min can provide respiratory support, but it doesn't directly address the problem of tenacious bronchial secretions. Oxygen therapy primarily aims to improve oxygenation, not facilitate mucus clearance.
Choice D rationale:
This is the correct choice. Maintaining a semi-Fowler's position (head of the bed elevated to approximately 30-45 degrees) can help improve lung expansion and facilitate drainage of bronchial secretions. This position helps to reduce the pooling of secretions in the airways, making it easier for the client to cough and bring up the mucus.
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